Skills Checklist – Cath Lab

Name
First Last
Phone
Email
Procedure/Skills*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Obtain & Interpret 12 Lead EKG
Defibrillation/Cardioversion
Interpretation of Arrhythmias
Perform Physiologic Monitoring*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Record LHC/RHC
Record Aortic/Mitral Valve Cases
Record EP/Ablation Cases
Record Perm. Pacemaker Insertions
Circulate For*
Rarely Some Experience Proficient Trainer / Preceptor N/A
LHC/RHC
PCI (Interventional)
EP/Ablatins
Permanent Pacemaker Insertions
IABP Insertions
Place Leads & Pads for Cardiac Mapping

Scrub For*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
LHC/RHC.
PCI (Interventional).
EP/Ablatins.
Permanent Pacemaker Insertions.
IABP Insertions.
Knowledge of/practice Radiation Safety
Check and Mark Distal Pulses
Perform Allen Test

Medical Administration*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Antiarrthymics
Antibiotics
Atropine
Anticoagulants
Beta Blockers
Conscious Sedation
Sedation Reversal Agents
Emergency Medications
Pulmonary*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Airway Management
Ventilator Management
O2 Therapy & Delivery Systems
Pulse Oximetry
ABG Interpretation
Post-Procedure - Monitoring & Documentation Of:*
Rarely Some Experience Proficient Trainer / Preceptor N/A
- Vital Signs
- EKG
- Level of Consciousness
- Insertion Site
- Distal Pulses
Use of Aldrete Sedation Recovery Scale
Maintain A/V Sheaths in Place
Post-Procedure - Set-Up & Maintain:*
Rarely Some Experience Proficient Trainer / Preceptor N/A
- Arterial Sheaths to Pressure & Monitor
- Swan Ganz via Venous Sheath to Monitor
Obtain & Monitor ACT
Removal of AV Sheaths
Manual Pressure Hold
Post-Procedure*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Clamp Hold
Radial Hermoband

Post-Procecure - Vascular Closure Device*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
- Application
- Monitoring
Sterile Pressure Dressing Application
Maintain IABP
Maintain Temporary Pacemaker
Crash Cart Use
Suction
O2 Administration
Emergency Meds
Education of Patients/Family

Equipment*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Hemachron
Medication Dispensing Systems
ABG Analysis Machines
ACT Machine
PTCA Balloons
Stents
Athrectomy
Laser
Power Injectors
Doppler
Computer Charting Systems

Do you speak any languages other than English?*
- No
If yes, enter languages above, separated by commas.

Age Group Experience*

Confirmation*
- I attest that the information I have given is both true and, to the best of my knowledge, represents an accurate self assessment of my professional skills and/or education.
Signature
Date
MM slash DD slash YYYY

Origin Travel Nurses has earned the Joint Commission's Gold Seal of Approval

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Obtain & Interpret 12 Lead EKG
Defibrillation/Cardioversion
Interpretation of Arrhythmias

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Record LHC/RHC
Record Aortic/Mitral Valve Cases
Record EP/Ablation Cases
Record Perm. Pacemaker Insertions

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
LHC/RHC
PCI (Interventional)
EP/Ablatins
Permanent Pacemaker Insertions
IABP Insertions
Place Leads & Pads for Cardiac Mapping